Provider Demographics
NPI:1508346867
Name:CALLIS, GERALD (COTA)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:CALLIS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2537 GOLDEN BEAR DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-2377
Mailing Address - Country:US
Mailing Address - Phone:215-552-6817
Mailing Address - Fax:
Practice Address - Street 1:2537 GOLDEN BEAR DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-2377
Practice Address - Country:US
Practice Address - Phone:215-552-6817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207979224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant